Through the support of the Center for Global Health, I travelled to Uganda in October 2012 to continue my research looking at behaviors around antimalarial bednet use in poor households.

Malaria is one of the world’s biggest barriers to achieving the Millennium Development Goals for improving child health. Malaria kills nearly 650-1,000,000 people a year world-wide. It is the leading killer of children under five years old in sub-Saharan Africa, where 1 in 8 children die before age five. Insecticide-treated bednets are the mainstay of malaria prevention. Ownership of an insecticide-treated bed net in a household is associated with an 18-23% reduction in mortality in children under the age of five.

Uganda has the world’s highest malaria incidence, with a rate of 478 per 1000 people per year. Malaria represents the leading cause of health care visits and is the cause of 70,000-100,000 child deaths annually. Universal access to insecticide-treated bednets has been the official policy since 2009, with 7.2 million bednets distributed in 2010 alone. However, in 2009 only 1.5-20.2% of children under 5 slept under a bednet the night before and a subsequent study in 2011 showed only 28% coverage. Obstacles to bednet use in rural sub-Saharan African households have direct effects on child survival.

Bednets are typically composed of lightweight netting impregnated with insecticide and are meant to be hung above sleeping areas and unfurled during sleeping hours. Bednets provide a personal level of protection by protecting those sleeping under the net during the evening hours when mosquitoes are most likely to bite and transmit malaria. In addition to providing individual protection from malaria, bednets treated with insecticide also provide a level of community protection by acting as a vector control device. The insecticide kills mosquitoes at the point of contact with the net and interrupts the ability of that mosquito to spread malaria in the surrounding households during a subsequent blood meal.

I am particularly interested in the factors that determine whether or not a household will use a bednet. As I do on all of my visits to Uganda (this was my third in the last year), I spend part of my time with health workers in rural villages visiting households and asking them about their experiences with mosquito nets and some of the challenges they face in using them.

One of the most striking aspects of my time in Uganda was discovering the non-trivial barriers that exist to ensuring the ultimate goal of daily use of bednets. These barriers include obtaining a net, mounting it over a bed, and consistent daily use. Villagers complained that nets for purchase are often too expensive for them to afford. And even if they could afford them, they would have to travel to a market an hour away by foot to obtain one. According the health workers and villagers I interviewed government and other distribution programs consistently failed to meet demand for the nets.

There are many anecdotal reports of diversion of bednets, use of nets for fishing and even for wedding veils. You can see the photo attached of a bednet repurposed for use as part of a chicken coop. There are also prevalent rumors about the negative health effects of nets, including fears that they reduce male virility and contact with the netting can cause rashes and other illnesses.

And even once nets are obtained by a household, other challenges remain. Mounting a net in a household is a challenge when houses are made of brick or mud covered walls making it hard to attach the nets by string to the walls. And once a net is mounted, the family members need to remember to consistently use the net in the correct way, even during the hot and humid seasons when being under a net can feel oppressive but is most important due to the prevalence of malaria.

I brought to Uganda some experience with mosquito net programs in Madagascar as a Peace Corps volunteer 2003-2005. But following my work in Uganda I am working on performing a systematic review of literature on the determinants of household use of bednets. My hope will be to develop a conceptual framework for bednet use behaviors similar to which exists for medication adherence in HIV or TB. The idea would to begin developing ways that we can help people overcome these barriers by understanding in a more systematic way the types of barriers that people face (economic, education, geographic, habit, etc).

If we don’t help people overcome the barriers to use, we will not be able to see the benefits of bednets for the people and many children who need them the most.